Impaired Gas Exchange and Ineffective Airway Clearance
1. Impaired Gas Exchange related to
- alveolar-capillary membrane dysfunction (inflammatory effect)
- impaired oxygen-carrying capacity
Goal: patients showed improved ventilation and oxygenation of tissues
- gas exchange can be maintained
1. Assess the depth of breathing frequency.
R / to evaluate the degree of respiratory distress or respiratory disease process.
2. Elevate head of bed, help patients choose a position that is easy to breathe, encourage the patient to deep breathing, or mouth breathing.
R / oxygen delivery can be improved with a high seating position and breathing exercises to reduce airway collapse.
3. Auscultation of breath sounds, defect area decreased airflow / noise addition, (crackles, wheezing, dim).
R / breath sounds may be dim due to reduced air flow, indicates the presence of wheezing bronchospasm.
4. Palpation fremitus (vibration vibration on palpation)
R / vibration reduction suspected fluid collection.
5. Evaluation of the level of activity tolerance.
R / for respiratory distress severe / acute, the patient is totally unable to perform daily activities
6. Monitor vital signs and cardiac rhythm.
R / tachycardia and changes in blood pressure that may indicate the existence of systemic hypoxemia on cardiac function.
7. Supervise / picture series blood gas analysis and pulse
R / PaCO2 usually increases (bronchitis, emphysema) and PaCO2 generally decreased, resulting in hypoxia.
8. Give supplemental oxygen in accordance degan indicative of the results of blood gas analysis and patient tolerance.
R / improve or prevent worsening hypoxia
9. Assist patients in intubation, provide / maintain mechanical ventilation.
R / occurrence of respiratory failure that requires rescue efforts will come alive.
2. Ineffective Airway Clearance related to increased production of sputum
Goal: patients exhibit achieve airway clearance.
Clients can maintain effective airway
1. Auscultation of breath sounds, record the presence of breath sounds, eg wheezing, crackles.
R / some degree of bronchial spasms occur with airway obstruction and there adventisius breath.
2. Assess the frequency and depth of breathing chest movement
R / breathing shallow and asymmetrical chest movements often occur because of discomfort chest wall movement / lung fluid.
3. Give fluids at least 2500 ml / day, unless contraindicated, offer warm water.
R / liquid (especially hot water) to mobilize
4. Observation color skin, mucous membranes and nails
R / cyanosis nails shows the vasoconstriction, cyanosis of mucous membranes and the skin around the mouth indicates systemic hypoxemia.
1. Give medication as indicated
R / relaxes smooth muscle and reduce local congestion
2. Provide additional humidifier, eg ultranik nebulizer, aerosol humidifier room
R / humidity decrease the viscosity of secretions and facilitate secret spending.
3. Provide respiratory treatment, eg, chest physiotherapy
R / postural drainage and percussion parts esse